Indian J Pediatr 53 : 397-400, 1986

Long term prophylaxis of febrile seizures K. Ramakrishnan and Kurian Thomas

Department o f Pediatrics, Institute o f Child Health, Medical College, I(ottayam, agerala

Four different prophylactic regimen were tried in a group of 120 children, admitted for first attack of febrilc seizures, and followed up for a period of 5-6 years. The most effective regi- men found to be, was with antipyretic and diazepam during the period of febrile illness. Continuous, as well as intermittent phowbarbitone therapy was found to be ineffective in preventing recurrence.

Key words : Seizures; phenobarbitone; diazepam; paraeetamol.

Febrile seizures are one of the com- monst pediatric neurologic problemsA Though there is a genetic predisposition to the development of febrile seizures,2, 3 it does not occur along with pyrexia due to all illness. 4

The long term management of a child with febrile seizures is a matter of con- troversy. This tempted us, for conducting a long-term prospective study of such children, with four different therapeutic regimen.

Material and Methods

This study consisted of 120 children admitted for first attack of febrile seizures in the Institute of Child Health, Medical College, Kottayam, from October 1977 through July 1979. We included cases of seizures occuring with pyrexia of extra

Reprint requests : Dr. K. Ramakrishnan, Assistant Professor, Department of Pediatrics, Institute of Child Health, Medical College, Kottayam 685008 Kerala.

cranial origin in a child, who was pre- viously normal neurologically.

AU children were subjected to throat swab culture, mantoux test, and chest X-ray. Widal agglutination test and clot culture were done in all those who had pyrexia for more than one week. All children were subjected to lumbar punc- ture immediately after admission and cerebrospinal fluid was cultured for microbial growth to rule out the possi- bility of early meningitis. Electro-encepha- logram (E.E.G.) was not done in any of these patients.

, These children were randomly divided into 4 groups of 30 each. Age of the children varied from two months to six years.

Group I. They were given phenobaxbi- tone 3-5 mg/kg/day orally in two divided doses, from the time of admission and continued regularly for a period of i year of seizure free period, after discharging from the hospital.

Group H. They were given phenobarbi-

398 THE INDIAN JOURNAL OF PEDIAT1LICS

tone with same dose, but at the time of discharging from the hospital, they were advised to take it only during the period of febrile illness.

Group IIL Instead of phenobarbitone, diazepam (Valium) was given in a dose of 0-2 mg/kg/dose orally, thrice daily, during the period of febrile illness.

Group IV. No anticonvulsant was given. All the four groups were given anti-

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pyretic (paracetamlol) at the time of fever and antibiotics, if indicated. They were followed up at monthly intervals for a per iod varying from 5-6 years and obser- vations noted.

Resul ts

The results of the study are given in Table I , I I and I I I .

Test for proport ions was applied to find out the statistical significance of the

Table I. Types of seizures noted during first attack

Group 1 Group II Group Ill Group IV

Ocular fit (lasted < 10 rain.) 6 Generalised seizure lasted <10 rain.) 20 Generalised seizure ( ~ 10 rain,

but -( half an hour) 4

7 5 6 20 21 22

3 4 2

Table. II. Types of seizures occured in the family

Group I Group II Group III Group IV

History of epilepsy in any of the parents 3 Febrile seizures in any of the siblings 4 A febrile seizures in any of the siblings 3

2 2 Ni 3 12 Nil

I Nil

Table IIL No. of children who had recurrence and their relation to positive family history

Group I Group II Group III Group IV

No. of children who had recurrence during the follow up period 9

Association of recurrent febrile seizure to positive family history 1

5 Nil 6

Nil Nil Nil

RAMAKRISHNAN AND THOMAS : FEBRILE SEIZURES 399

findings. Findings in group I and II was not found to be statistically significant. Observations in group II and III were found to be statistically significant (0<0.02).

Discuss ion

Repeated febrile convulsions and simple febrile convulsions with subse- quent febrile illness are known to be commonS, 6 ranging from 12.3-54 per cent.

In two series,6, 7 long term anticonvul- sant medication was shown to have no effect in preventing the febrile convul- sions. In another study,8 phenobarbital levels were studied, indicated that 26 of 52 patients had levels habitually below the theraputic range. Oral phenobarbitone without a loading dose is useless as it takes days to weeks to achieve therapeutic blood levels by this route alone.9, I0

Several workersS, 11 have found that phenobarbitone reduces recurrence, but others have been doubtful.7,12 Pheno- barbitone significantly reduced recurrence among children under 14 months old at the time of first convulsion, but not among older children) 3 Intermittent therapy with phenobarbitone advocated by somO 4 does not appear to be of value. Rectal diaze- pare solution has been used by some for the control of acute convulsions in child- renA s Prophylactic treatment of febrile convulsions, diazepam in solution offers hardly any advantage over supposito- riesA6 In a series of children after first attack of febrile seizures, diazepam was administred as suppository, 8th hourly when the rectal temperature >~38"5~ Effect was compared with a control group of continuous phenobarbitone therapyA 7 No antipyretic was given. No change in

recurrence was noted in either of these groups. Recurrence occurred in 16 per cent diazepam group and 15 per cent in phenobartbitone group. No report is available in literature about the long term management of febrile seizures with oral diazepam.

In our series, there was no recurrence in group III, where as it occurred in all other groups. There was no statistical significance between the findings in group I and II whereas, it was significant between group III and II, and obviously with other two groups also. No correla- tion was noted with recurrence and a positive family histoi3r of convulsions.

From this study, we conclude that successful long term prophylaxis of a child with first attack of febrile seizure is achieved by putting him on oral diazepam and paracetamol during the period of febrile illness. Continuous, as well as intermittent phenobarbitone therapy is of no value in preventing recurrence of febrile seizures. Diazepam is a safe and quickly absorbed anticonvulsant, virtually free from undesirable side effects and there is little parental resistance to it. This is in contrast to the well known side effects of phenobarbitone.

Acknowledgement

We are thankful to Mrs. G. Sarasa, Lecturer, /n Statistics, Medical College, Kottayam for her valuable help in the statistical work.

References

1. OueUette EM: The child who convulses with fever. Pediatr Clin North Am 21 : 467, 1974

2. Frantzen E, Lennox-Buchthal M, Nygarrd A: A genetic study of febrile convulsions. Neurol 20 : 909, 1970

3. Lennox-Buchthal ,M: Febrile convulsions, a reappraisal, EEG Clin. Neurophysiol suppl 32: 138, I973

400 THE INDIAN JOURNAL OF PEDIATRICS

4. Ramakrishnan K, Mathew KN, Kurian Thomas: Causes of fever in febrile seizures. Indian J Pediatr 49: 367, 1982

5. Livingston S: Febrile convulsions, compre- hensive management of epilepsy in infancy, childhood and adolescence. Charles C Thomas, Springfield, Illinois, 1972 p 16

6. Milliehap JG: Febrile convulsions. New York, Mac Millan, 1968

7. Livingston S: Infantile febrile convulsions. Devel Med Child Neurol 10: 374, 1968

8. Faero O: Kastrup KW, Nelsen EL et ah Successful prophylaxis of febrile convulsions with phenobarbital. Epilepsia 13: 279, 1972

9. Buchthal F, Lennox-Buchthal MA: Pheno- barbital, relation of serum concentrations to control of seizures. In woodsburry DM ed: Antiepileptlc drugs. NY, Ravenpress, 1972, p 335

10. Svenmark O, Buchthal F: Diphenyl hydan- tion and phenobarbital serum level in children. Amer J Dis Child 108 : 82, 1964

l l. Wallace J, Aldrige Smith J: Successful pro- phylaxis against febrile convulsions with val-

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proic acid or phenobarbitone. Br Med J 280: 353, 1980

12. Heekmatt JZ, Houstom AB, Clow BJ et ah Failure of phenobarbitone to prevent febrile convulsions. Br Med J 1 : 559, 1976

13. Bacon C J, Mucklow JC, Rawlins MD et ah Placebo controlled study of phenobarbitone and phenytoin in the prophylaxis of febrile convulsions. Lancet Sept. 19, p 600, 1981

14. Vanden Berg BJ, Yeru Shalmy J: Studies on convulsive disorders in young children, J Pediat 79: 1004, 1971

15. Hoppu K, Santavuori P: Diazepam rectal solution for home treatment of acute seizures in children. Acta Paediatr Seaad 70: 369, 1981

16. Knudsen FU: Rectal administration of dia- zepam in solution in the acute treatment of convulsions in infants and Children. Arch Dis Child 54: 855, 1979

17. Knudsen FU, Vestermark S: Prophylactic diazepam or phenobarbitone in febrile convulsions, a prospective controlled study. Arch Dis Child 53: 660, 1978

M I D D L E EAR CHANGES AFTER TREATMENT OF OTITIS MEDIA

The main abnormalities in acute otitis media are inflammation of the mucosa lining the middle ear, the ossicular chain, and the deep surface of the tympanic mem- brane; an effusion; and reduced air pressure with retraction of the tympanic membrane. The duration of pathological changes after resolution of the acute infection is uncertain. These changes have been implicated in the causation of deafness, and long-lasting effu- sion is thought to be a causal factor in chronic serous otitis media or glue ear. In addition persistent effusion could predispose to the recurrence of acute otitis media. Black has suggested that the epidemic of surgically treated glue ear is due to unnecessary surgical treatment of effusion that would have resolved spontaneously.

Tympanometry was used to identify middle-ear changes in 154 children with otitis media during and after treatment in general practice. In two hundred and nineteen episodes, 242 infected and 196 non-infected ears were examined. The results suggest that chronic serous otitis media or 'glue ear ' is not a consequence o f acute otitis media; that persistence of middle-ear effusion is unlikely to predispose to recurrent acute otitis media; and that in unilateral otitis media abnormalities are often present in both ears.

Abs t rac t ed froth :

Wheeler MTK : Lancet 1986; i : 529-531.